30959' `'APPLICANTTO FILL IN INFORMATION WITHIN RED LINES • USE BALL POINT PEN ONLY .
CITY OF CUPERTINO o' BUILDING - ELECTRICAL. -
UUIf DING DIVISION APPLICATION/PERMIT PLUMBING - MECHANICAL
BW LDING PRUII:CI'IDF.NTIFICATIUN
PERMIT NO. 130959
`
BUILDINGAIIDRESS
'SANITARY NO.
„
APPLICATION SUtlMI'PI'Ah DATE
OW ER'SNAME: .'
.. PHONE.
�CBITECPIRNGINE K f "ICNO:
°'
CONIRA: OAME: - V LIC NO
V' ✓1
ADDRESS
�/b.f� tLEA1JZiF gum. r„ 3'-
N/C
CONTROL #
- CONTACT: I' PHONE : "�-
• - t -
_p ,. -
❑ Consultant Fees Paid by Applicant (Initial)
�. BUILDING PERMIT INFO
BLU ELE PLUMB " MECH
❑ ❑,
{y�OO
F W..
G V F
F
_ LICENSE D CONTRACTOR S DECLARATION
f Chapter 1( g
ishS i 900)fDivision 3 dtbvBUSi 'and Profass'o -COJeu Imylie a
-
f ti ff (/9 /_ / -�
-icense Clus " /'� Cm # 1 riw�
Data Lic. is nor ''
QTY
• ELECTRIC PERMIT
-
FEE
,t ' ' JOB DESCRIPTION .
RPGI Ate' _ ,i.' '
"OSFOWL ❑ KITCHEN REMODEL
❑ ADDITION • 0 PLUMBING RE -PIPE
'OMULTI -UNIT. s. -El STRUCTURAL
MODIFICATION
I ❑INTERIOR ❑CHIMNEYREPAIR
'IMPROVEMENT '
El BATH REMOpLL/REPAIR [I DEMOLITION t
T
El TITER L/ it
,
PERMIT ISSUANCE T
� -
pePL1ANCES- RESIDENTIAL
'FOy>
2OrnA
OZ4,
'. ARCHITECT'S DECLARATION
'I , 1unJerswnd ney Plans .hull M1e owed its puhlic recoMS
PANELS -
UP TO 200 AMPS,
0. V
c.,
cp
Lae el pair .:' al
OWNER-BUILDER DECLARATION
I hereby all ear that 1 exempt f 11 C t L e 'e'La t o e
. Code •
Fallowing mason (Socn 7031.5, Business I P of a os , Any c ly or forms,
whch 4 re uPaduch I t h p 1 I;h rcP y:u d
prior t t s issmurfe, also r9 re's the PTlicam t such pe ndind file. ki,rcd,dro,mem
that h d pursuant the provisions f [lie Contractor s License L' (Chad (Chader 9.
_
201= 1000AMPS'
_
'OVER Wild AMPS ''
_
SIGNS ELECTRICAL
-
SPCCIALCIRCUIT/MISC'
I HMP MET ER OR POLE INST.
COMMERCIAL,
reournincerin, with S I ]000) of D .er 3 f life Business and Professions Code) a,
X GW F ' y
G
G
Ihe, h I. xempl Ihemtrod, end the bees f 'the alleged exe tpuo t. Any v olu[ on or
Section , 9. 0ih 3 1.5 f by h ah l y p d a pppdednd et a nII , ferriteP.) . I . . y wth
I p s
will do k dlhe3 t : I I Id feeJY "'le 4 BU.s
and Profession, Call Fre C w t . License Law does not apply to of
who builds or' amp t.as maroon ad eho d res such oars Iumsdf or through
� NE HIAG/ADDITION ❑ DEMOLITION
❑. TENANT - El FOOD SERVICE
IMPROVEMENT
.O OTHER -
-, , -
POWERDEVICES
SWIMMING POOL ELECTRIC t
-
T
OUTLETS- SWITCHES - FIXTURES
-
progeny
his own employees provided that such improveirmits not Intended or offered far
sale if however the heldingr improvement is sold wphn one year ofcomplcuon, the
NEW RESIDENTIAL ELECTR SOFT.,
SQ. FI'. F6 A�A
VSQ. FT.
, -
ys u
owner-builderwin h ave mouraden nranving lhthe ddn tb Id p far gm.
pass, at sele. I
Y caner ol'the memory. am exclusively nl i g no licensed carried... it;
I
_
11:•RfC� •
T
c nsimettli project (S 9(144 Boonessaird Professions C de:) The Compact or s 1'
cense'Le. does not apply to f property a no h 'Id. or improve, 0 d'
who contracts for such prof t. thacontt t OPeened pursuant t Ih Contractor,
VF' py�
Guilt
CL7
'
QTY - PLUMB G RMIT
FEE
.
PERMITISSUANCE
License Luw• „
❑ I am exempt under Sec. _ , B & P C far this reason ,
I� NQ
r
Owner Dum - r
ALTER -DRAIN A, VENT -WAT ):`
VALUATION
L IJLJ
.WORKER S COMPHNSAI ION DECLARATION
[the rchy affirm under pensltyafpepurynnenRbe toll 6d 13tions:.
RACK FLOW PROTECT,
S'anon,as
.mod hav amaxid_,unlnin a Cenifcate uncertain or self- insure for Worker's•Compron-
Provided for by Section 390 of the Lefor Code, Itir the poffarnr,cof the'
DRAINS - FLOOR, ROOF, A EA, ND.
STORIES ',
9'Y PE CONSTRUCTION
work for which this moral is issued. •.
❑ 1 and w' ainti n Worker' at Insurance, as oxmired by Section
eeL tcco
'FIXTURES- PERIRAP `
I
'
GAS -FA SYSTEM- INC. OUT[ --
'
-
3"100 Of due, f ark for, hiefih's permit is sued
My Pohcy number are.
It
-
OCC.GROUP'
APN
GAS -EA. SYSTEM-OVER 4 (EA)
CL "{ AI'I. OF XEMI PION FROM WORKERS
COMP SATION INSURANCE
( t setLh+t completed fth ce t sfnr one hunJroJ Anllars (810)
or sJ ",:" - pro
r +
-
GREASEINDUSTRL WASTE INTERCEPTOR
-
BQILUINODIVI910NPHA9
GREASETRAP 't
_
PLANCHF.CK PP.F,
„ /J1
_t
SEWER SANITARY STORM EA. 200 FEE
p
z 0
Uj
i
Z
LULL O
Q,ULenders
> W
Z)
,V
I miry that in the perfameareaufihe work far which this permit is is,ded.[,bull
.at p y yp am y ast freedom subject the W k C p n-
Zia sna I fC lifd -
Applican t _
NOTICE TO APPLICANT If - ante to g his Certitude. of E.frial on you should
become subject to the Worker's C p n. 1 p of the Lahor Cute, you must
fdnhw th comply with h proarsiams (ir this permit shall he defined revoked. _
CONSTRUCTION LENDING AGENCY. -
Ihereby affirm that t ra I di gagmay for the performance of
the walk far which this Normal is ierned (Sec 3099 Civ C)
Name
ENERGY FEE
,
WATER HEATER WIVENVELECTR
_
WATER SYSTE?MIPREATING , -
WATER SERVICE
,
GRADING FEE -
SOILS FEE ,
PAID
-
"h
NEW RESIDENTIAL PLMhU SQ:TT,
D t Reacipuls
-
1 TOT AL.
Lender's Address --
,1 eendy that 1 have ad this application and stmallair th h Iva informuunn is
came t `1_ agree to ply with all city anti - county adanduce,, and state laws minding to
buildng molOUlnn, and hereby authorize p samernes orth'. it,, m emmaque the
n � TOTAL:
c
BUILDING PEE
QTY' MECHANICAL PERMIT
M'FEE
SEISMIC FEE ,.
�' -, ..
-
toneJ properayf sp I' Orp...
) egrca m save, d p h :: Ih C ty Croatian 'egatvsi
PERMI'CISSUANCE--
�.
ELECTRIC EE
ALTERORADDTOMECH.
PLUMBING PEE
-
jdgmems costs and expenses which are, many wtry accrneagairm sued City
c elf the nog id this purn.
AIR HANDLING UNIT(TO 10,(100 CFM)
MECHANICAL PEE
)APPLIC N ON .STANDS AND WII O MPLYW H, ALL'NON-POINT
G TIONS..'
AIR HANDLING UNIT(OVER IQOW CFM)
CONSTRUCTION TAX
`
mraa pphcanl/ memr Dote
AZARDOUS M RIALS DISCLOSURE `
EXHAUST HOOD(WIDUCI)
r'ti,
HOUSINGMITIGATIONFEE.'-
-
,
HEATING UNIT (TO 100,00 B1 V)
-
+•
i
r
r"With evpplicu - t king occupam store or handle hmm opens mmerlel
is defined b the Cupmino Municipal Code,'Chapter 9J2, and the Health and Safety
Coda, Serum 25532001 - ", _
❑V. (ONo - "
Will the airccant future building by BtyAcoup t r Micaswhich
t ha and air coinaml
Y. naO NS Aefine'll by t+e Bay Ara An Quality Management
tsl It °
HEAPING UNIT (OVER 100,000 B' 1' U)
'
PAID
e
VENTILATIONFAN(SINGLLRESID)'•
Dnte R ell#
P
-
-
1
'BOILER COMP (3HP OR'IUB OBU BTU).
"
- ".TOTAL
BOILER - COMP (OVER lorkoo d1U)
AIR CONDITIONER .l
d
read hazed materials q n c under Chapter 6.95 of Cali-
ISSUANCE DATE
NEW RESIDENTIAL MECH. •' SQ Fp.
Health af tY C de Se r .25505 25Ai d 25534 I J rsmnJ Ihm If the
currently have d tern, that l k nryrespn¢Ihl ly m notify the occupant
L
"
la which must be met prior In issunnw of n Cenifcate of Oeeupanoy.
ISSUED OY:"
ad agent - Data
TOTAL:
„
r" OFFICE